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How Should the Affordable Care Act Be Judged? How Will It Be Judged?

As you read this, the Affordable Care Act is being judged.

The media and the public in recent weeks have cast a wary eye toward the ACA, what with the glitchy rollout of and a quartet of congressional hearings that featured bipartisan grilling of HHS Secretary Kathleen Sebelius and CMS Administrator Marilyn Tavenner.

Meanwhile, aspects of the law soon will be judged, literally, by the courts. Several lawsuits challenge the legality of providing subsidies via the federal exchange, while another suit questions the federal contraceptive coverage rules included in the law.

With the attention focused on the problematic website and the looming lawsuits, health policy experts and regular Americans alike are measuring the effectiveness of the law and deciding whether they like it.

However, it’s not how people feel about the law right now that ultimately will decide whether it is a success or a failure. Should the law survive the barrage of website problems and the multitude of lawsuits, a more measured response would be for observers to dip into their reserve of patience and wait until the law has had time to put down roots. In a matter of years, there will be more real-world data on the law — instead of estimates and conjecture — making it easier for experts to assess how each of the ACA’s provisions is performing.

Still, even with that time, two questions arise: How should the law be judged? And, perhaps more importantly, how will it be judged?

To find out, California Healthline talked with a number of health policy experts, including those who support the law and others who oppose it.

First, Acknowledge the Complexity

Timothy Jost, a health law professor at Washington & Lee University and one of the nation’s leading experts on the ACA, said before even beginning to judge the law, one first must acknowledge the difficulty of assessing it.

As Jost noted, the ACA “set out to do an incredibly difficult task, which is to take a system that already works pretty well for most Americans and does not work at all for many, and to fix it so that it will continue to work well for most Americans but now work well for the people who are currently closed out, as well.”

He added, “It’s like fixing an airplane while it’s in flight, if there is something terribly wrong with the plane.”

Ed Haislmaier, the Heritage Foundation’s senior research fellow at the Center for Health Policy Studies, agreed. “This law is much more complex than most cases,” he said, adding, “If you compare this to proposals in other areas, or even in health care, this is vastly more complicated.”

How Should the ACA Be Judged?

With such a complex law, it is difficult to pinpoint just exactly how to measure success. While Jost initially argued that the ACA should be judged by “all of the things it was trying to accomplish,” he conceded that its “primary purpose” is to “expand coverage for people who are currently locked out insurance coverage because either they can’t afford it or because they have health issues, or both.” Under that framework, if the uninsured rate and that expansion in coverage “has not undermined” employer-based and public insurance programs down the road, then the ACA will have “succeeded,” he said.

Although Haislmaier opposes the ACA, his take on how the law should be judged is similar to Jost’s. He said health policy experts will ask of the law, “Does it make the system better or worse?” The answer, to Haislmaier, will be measured by four areas: “Choice, competition, cost [and] access.” 

Henry Aaron, a senior fellow in economic studies at the Brookings Institution, sees it slightly differently. He thinks there are three main areas by which the law should be judged:

Whether the insurance market reforms included in the law have “become standard practice”;

If the Medicaid expansion has “percolated through most, or nearly all, states”; and

Whether the insurance exchanges are “up and running and an accepted part of the insurance landscape.”

Other experts also have laid out parameters for judging the law. For example, in a recent paper titled, “The Affordable Care Act: A User’s Guide to Implementation,” authors Sheila Burke, a professor at Harvard University, and Elaine Kamarch, a senior fellow at Brookings Institution, present a series of questions to gauge “key benchmarks” for the success of the ACA. They believe some of the key metrics for the law are the uninsured rate, out-of-pocket spending, competition in the exchanges and the availability of employer-based coverage.

How Will the ACA Be Judged?

How experts judge the ACA is likely to be far different than how the general public will measure the law.

Haislmaier recalls polling in the 1990s — when the Clinton administration was seeking to pass comprehensive health reform — that found Americans were willing to pay more in taxes to cover the insured. “The folks who were pushing reform were all excited about that fact,” he said, adding, “When you actually asked the questions that probed, “How much?” you found that nobody really wanted to pay more than 50 bucks a year.” According to Haislmaier, that shows “there’s a real disconnect between the experts and the average person” when it comes to health reform.

Haislmaier thinks the public will hearken back to the 1980s and adopt a line from President Reagan. He said, “The metric the public is going to use is, ‘Am I better off, or am I worse, than I was?'” Haislmaier called the ACA a “pocketbook issue,” adding, “If you think you’re better off than you used to be, it’s going to be hard for somebody who’s a supposed expert to persuade you otherwise.”

Jost thinks the media will play a large role in how the law will be judged. Jost said, “[I]f the news media continues to focus on” relatively high-income U.S. residents who might have to “pay a little more for their health insurance,” then it will be difficult for the law to gain traction. He added,”[I]f that’s the main story … a lot of people are going to see the thing as a failure.”

It is difficult to foresee how the public will view the law. However, if current trends are any indication, the law faces a difficult road ahead.

According to Aaron, Americans tend to have a negative view of the U.S. health care system, seemingly inherently, and adding a major reform only serves to exacerbate that view. “People have been discontent about the U.S. health system … for a very long time,” Aaron said, adding, “They’ve griped about it, they hate insurance companies, they love their doctors.”

Aaron jokes that the ACA is going to bear the brunt of what he calls “that grumpiness.” He says, “Not entirely facetiously, I say to people that if somebody gets eczema, they’re going to blame it on the Affordable Care Act.” However, Aaron also noted that he believes that if the ACA can survive and “becom[e] the status quo,” the harsh lenses it is currently being viewed through could become slightly rosier.

For certain, deciding how the law will be judged is a lot of conjecture and guesswork. However, there is one surefire way to gauge the success of the ACA. As Jost says, “If the website isn’t working in five years, that will have been a failure.”

Around the nation

Here’s a quick look at other interesting stories popping up along the road to reform.

The effect on Obama: David Horsey, writing in the Los Angeles Times “Top of the Ticket,” wonders how much damage the problems with and the wave of insurance policy cancellations will do to President Obama’s second term.

Another take on measuring the ACA: Politico asks the question, “Obamacare: What defines success?” Writer David Nather notes that Democrats still are seeking the broader goal of creating a “health care safety net that closes huge gaps and helps all Americans.”

Drinking away Obamacare: Generation Opportunity, the conservative group seeking to convince young adults to opt out of enrolling in coverage through the ACA’s health insurance exchanges, has found a new way to get its message to college students: partying.

A class in counting: How is the Obama administration tabulating ACA enrollment figures? The Washington Post‘s “Wonkblog” has the answer.

The opportunity in Obamacare: Although the business community at large sometimes takes a dim view of the ACA, some tech companies are looking to take advantage of the law’s coverage expansion to provide consumers with “slick online tools” to help people manage their health. 

Related Topics

Road to Reform The Health Law